<h1>Request Group Rate</h1>
<form>
    <input type="hidden" name="referrer"/>
    Name: <input type="text" id="fieldName" name="name"/><br/>
    Group Size: <input type="text" name="groupSize"/><br/>
    Email: <input type="email" name="email"/><br/>
    <input type="submit" value="Submit"/>
</form>
<script>
    $(document).ready(function () {
        $('input[name=referrer]').val(document.referrer);
    });
</script>